Medical and Pediatric Oncology 33:405–410 (1999) CHRONICLE LIVING HISTORY One of the monumental discoveries in medicine during the last century was that recorded by Farber et al. in 1948. The team at the Boston Children’s Hospital found that a simple compound administered systemically to children with leukemia caused a remission of the thitherto universally lethal disease. Members of that research team who were then Fellows were asked recently to record their impressions of those heady days. What was it like to see pe- ripheral blood smears, loaded with lymphoblasts, clear with the administration of aminopterin? To be present at such epochal moments in the advance of medicine and science comes but once in a lifetime. Drs. Wolff, Mercer, and Sylvester have graciously consented to let us share in their recollections. An additional echo of those days is provided by Prof. Ravindranath who, by chance, met one of the first patients cured of leukemia 45 years before. Giulio J. D’Angio, MD Editor-in-Chief First Light on the Horizon: The Dawn of Chemotherapy James A. Wolff, MD* Key words: childhood cancer; antimetabolites; chemotherapy; treatment of leukemia Prior to the end of World War II the management of leukemia in children. Various folic acid antagonists were patients with either acute or chronic leukemia was essen- utilized. The impetus for these studies arose from mul- tially that of supportive care. Neither surgery nor radia- tiple observations. tion therapy (RT), the standard forms of treatment for Folic acid deficiency was known to be associated with cancer, were applicable to acute leukemia, and RT had a bone marrow inhibition. Moreover, in 1944 Leuchten- limited role in the chronic leukemias. Whole-blood trans- berger and his colleagues in the Department of Pathology fusions were given, although not routinely, when anemia at the Mount Sinai Hospital in New York City reported became severe. Chemotherapy, which had been intro- that a “fermentation l. Casei factor” inhibited growth of duced for infectious diseases such as malaria and syphilis Sarcoma 180 transplanted in female Rockland mice [1]. by the beginning of the Twentieth Century, had virtually A year later the same group showed complete regression no impact on the treatment of leukemia or malignant in one-third of single spontaneous breast carcinomas in solid tumors. Chemical agents (colchicine, arsenic, ben- mice treated with intravenous injections of “fermentation zol) had been tried without success in chronic myeloge- l. Casei factor” [2]. At the time it was thought that this nous leukemia. Haddow reported the use of urethane in substance was folic acid. Later, Hutchings and his group chronic myelogenous leukemia in 1946, the same year in which the beneficial effects of nitrogen mustard deriva- tives in adults with lymphomas was reported. In 1947, at Professor of Pediatrics, Emeritus, College of Physicians and Surgeons, a time when the mortality for childhood leukemia was Columbia University, New York 100%, a group at the Boston Children’s Hospital, headed *Correspondence to: James A. Wolff, MD, 518 Isle of Capri Drive, by the late Dr. Sidney Farber, a pediatric pathologist, Fort Lauderdale, FL 33301. E-mail: [email protected] initiated a number of clinical trials for the treatment of Received 11 January 1999; Accepted 9 February 1999 © 1999 Wiley-Liss, Inc. 406 Chronicle at the Lederle Laboratories showed that the agent con- tained in the extract was a conjugate of folic acid, ptero- yltriglutamic acid (teropterin). Subsequent work at Mount Sinai Hospital showed that pteroylglutamic acid (folic acid) was not effective in producing regression of these breast cancers [3]. Moreover, Farber had himself found that administration of folic acid had “accelerated the leu- kemia process.” Finally, a report by Heinle and Welch [4] in 1948 stated that administration of folic acid was attended by rapid hematologic and clinical relapse in three patients with chronic myelogenous leukemia. Although the evidence that antagonists of folic acid Fig. 1. inhibited proliferation of leukemia cells was fuzzy at the time, Farber enlisted the help of Hutchings and other remissions in five children. Figure 4 of that report shows chemists at the Lederle Laboratories. One of them, Y. striking improvement in the bone marrow in one of these Subbarow, quickly synthesized a number of folic acid children (Fig. 1).1 The authors suggested a search for conjugates with antimetabolite effect, and the first clini- other folic acid antagonists that might be less toxic and cal trial of pteroylglutamic acid conjugates by the Farber even more effective than aminopterin. team was soon published in December, 1947 [5]. They Publication of the results of treatment with aminop- reported observations in 90 patients with advanced ma- terin aroused widespread interest throughout the world. lignant disease, of whom 41 were children and 49 were The Boston Children’s Hospital became the mecca for adults. All subjects were treated with pteroyldiglutamic a number of investigators interested in childhood leu- acid (diopterin) or pteroyltriglutamic acid (teropterin). kemia. Conferences were arranged for visitors to famil- Eleven of these patients had acute leukemia. In these iarize themselves with the details of treatment. Early subjects bone marrow biopsies performed before and af- in 1948, another folic acid antagonist, 1-4–diamino-N- ter therapy showed “no evidence of pancytopenia or 10 methylpteroylglutamic acid (originally labeled a- agranulocytosis.” Adult patients “experienced improve- methopterin, later methotrexate), became available to the ment in energy, appetite and well-being.” It was con- Boston investigators. Their subsequent studies showed cluded that the substances were nontoxic and warranted that this drug was less toxic and even more effective than further investigation. aminopterin. The Farber group’s experience with folic Following the initial clinical trial, Farber joined with acid derivatives was recognized quickly as a paradigm in Dr. Louis K. Diamond, a pediatric hematologist, Drs. the search for other agents to combat childhood leuke- Robert D. Mercer and Robert F. Sylvester (Research Fel- mia. The Boston Children’s Hospital continued to play a lows in Pathology and Tumor Research), and myself (Re- leading role in this endeavor. Farber, with great energy search Fellow in Pediatric Hematology) to form a team. and foresight, had established the Children’s Cancer Re- Its mission was to investigate the effects of folic acid search Foundation (CCRF) in 1947, when he introduced antagonists in children with acute leukemia, which had the first research program in chemotherapy devoted to not yet been stratified at that time into morphologic childhood cancer. The “Jimmy Fund” became the fund- types. These patients therefore included children with raising arm for the CCRF. The CCRF charter was ex- acute myelocytic as well as acute lymphocytic leukemia. panded in 1969 to provide services for patients of all The first child in this study began treatment on December ages, and was renamed the Sidney Farber Cancer Insti- 3, 1947. Between that time and April 15, 1948, 16 chil- tute in 1947 in honor of its founder, one year after his dren with acute leukemia were treated with 4-amino- death. Nine years later, it became the Dana Farber Cancer pteroylglutamic acid (aminopterin) intramuscularly. Institute, as it is known today. These children were all seriously ill at the start of treat- On reflection, the passage of 50 years has not dimin- ment. Ten of them showed significant clinical, hemato- ished for me the heady excitement that accompanied Far- logic, and pathologic evidence of improvement lasting ber’s ground-breaking experiments. By and large, the several months. Six of the sixteen had poor responses. program had the enthusiastic support of our colleagues at Because of the reluctance of referring physicians to treat our institution, then known as the Boston Children’s acute leukemia, recruitment of patients was difficult and Hospital. A few nay-sayers, as may be expected, ad- became moreso as severe toxic effects became apparent. vanced arguments that overemphasized the potential of The investigation also met considerable resistance from the house staff, who were not accustomed to managing such severely ill children. The first report of these studies Reproduced with permission from N Engl J Med 1948;238:787–793. [6] on June 3, 1948, gave detailed data of temporary Copyright © 1948 Massachusetts Medical Society. All rights reserved. Chronicle 407 toxicity. Despite an early undercurrent of disapproval BIOGRAPHIC NOTE from these sources, the fairly obvious benefits to be de- rived overruled any objection. For me, there were, more- Dr. James Wolff was the only one of the three Fellows over, many satisfactions in addition to the realization, involved with this initial and epochal research who con- even back then, that very likely we had started down a tinued in hematology/oncology. He left Boston to join path that would benefit future generations of children. the Babies Hospital staff in New York City, a unit of the One of these was the opportunity to study the sequence of College of Physicians and Surgeons of Columbia Uni- events in the evolution of remission in patients with acute versity. Steadily, over the years, he built an academic leukemia. With the help of Betsy Gallatin, our accom- unit in pediatric hematology/oncology that proved to be plished research technician, we outlined in great detail one of the fertile training grounds for specialists in this the changes that occurred after chemotherapy in both the field. He was one of the original members of the National peripheral blood and the bone marrow. These proved to Wilms Tumor Study Committee as well as being a prin- be similar to those seen in the rare child who underwent cipal investigator in what has become the Children’s a brief remission spontaneously or as a result of febrile Cancer Group. His contributions to clinical research as infection.